05100156 CITY OF CUPERTINO '
BUILDING DIVISION PERMIT GpNTR .C`TQIt.TNFURMATI01V '
BUILDINGADDRESS: ABLE SEPTIC PERMIT"005100156
2601 VOSR AVE
WNER'S NAME: PERMIT ISSUE DATE
CITY OF CUPERTINO 520 REED ST
ONE: SANITARY NO. CONTROL NO.
(408) 377-9990
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
o l�
Loo LICENSED CONTRACTOR'S DECLARATION .u•
I 1 hereby atftrm that I am licensed under provision of Chapter 9 monamcnNng Job DeSC�'B }
with Section 70110)of DiAtlon Sof the Business and Frafusiwu Code.and my license is
^n in full force and cD«L L/-- CLEAN OUT Vi AilfeLeAgni
3~Z Diam%C AIrCHnECCi'o3 oFlu A I O ffffff '+
? I understand my plan shall be used u public records ////®®,����,�J Cr� /Af(
Q6 \ �Y
5 c Licensed Pmfassm"Al �C
OWNER-BUILDER DECLARATION / yg7
r.n @ 1 mem einem that 1 1. exempt Imre the Conuactora License law far the
y o o following renson.(Section 7133 nstru t.*lues and improve,
de Dns Coda:My city or county 1(y f 1
$Pi which mqulms a permit In construct.alar,improve,demmLm,orerepairsig any moment (jn
pdonn its icensed pursuant
also requite the ilio nof ronsucON Com permit to Rte se Law(Charter
t
F � (that he commeslicewithSection70WpmvivansoftimComrxuhLianselsonsCodmr9 Sq.F[.Floor Area Vjr -a\ua[ion
'q SC
(commencing I,exempt Section and
of basisofrM allegee 0 d
cuand Professions Cnde)of
6 3 g
that he 4 Tempi therefrom and Ne basis for the sllegcd eump0on.Any violWon of r
Section 7031.5 by any applicant fora permit subjects the applicant to a dNl penally of APN Number Occupancy
out mom than Rw bund.d dollars D500).
Ty�
❑I,As owner of the property,or my employee with wages As their sole marten adon,
will de the work and the"'muse is not intended oraReced for sak(Sm.70",Business Required Inspections
and Pmfeaions Code:The Consommes License law does an[apply u e an owner of q p
property who bu Ilds m improws thereon,end who does suc h work himself or thmagh his
own employee.provided that such imprownumas Ara notimended moQered forsaln It.
however,Ne building or improvement is mid within ON year of compkdon.Ne owner-
builtltr .will haw the burden of proving that he did am build ar improve for purpose of
sett.).
❑1,as owner of the properly,am eciudwiy contracting with licensed contractors in
construct the project(sec.7014,Business Amor Profesumts Cade:)The Cmtrecurs Li.
am law docs not apply to an owner of propeny.who Wilda of improws Neem.and,
who constants for such projects with s matrimonial licensed Pmsnnt in the Contractors
License Law.
❑I Am exempt under Sec .B A P C for this moon
owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury an of the following declarations:
❑1 have and will maintain•CerdMte of Consent to self-insum for WmkersCompen-
.don,u pmvldW fm by Section 3700 at the labor Code.fm the performance of the
work for which this permit is issued.
❑1 have and will maintain Workeea Compensation Insurance,As mquired by Sectio
3700 of Ne Labor Code,for the perfmroomm of the work for which this permit B issued.
My Worke is Compensation Insurance carrier and Policy number am:
"$1 Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section need not W<mrdshued if the pmmll is forone hundrtddellars(5100)
or it")
I certify Net in to performance of the work for which this permit u Issued,I shall not
employ Any person in an c to become subject to Me Wgters Compewdan
Lam of Califomi S-e,Y_ / rh. _..
APPlicant
NOTICE TO APF�CIJN:If.aAcr making Nis ceniima,of Exemption,you should
become subject to the Worms s Compensation provisions of Ne IaMr Coda,You most
O forthwith comply with such PmVISm.or this permit mall W deemed newked.
.Z.,yr CONMUCI'ION LENDING AGENCY
[ti► I hereby alarm that dare is a mnshuctinn lending agmmy,far the perfuranceof
!� the work for which this permit is issued(Sec.3097.Civ,C.)
W Q Lenders Name
z fanderS Address
V Q 1 certify that I haw must this application and suss that the Alan.information is
W F correct.1 agree to comply with W city and county ordinances and sum laws relating In
OU building construction.and hereby sutharien roptnenutive of this city m enter upon the
WI above-mentioned property for inspection purpnes
a (We)agree to saw,indemnify and keep harmless the City of Cupertino against
,..t NAbllltin,Judgmenu.cwu and expenses which may In any way acerae against said City
t) in consequence of Ne granting of this permit.
APPLICANT UND T S AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REG
Re-roofs
Signature of ppll HAZARDOUS MATERIALS DISCLOSURE Data Type of Roof
Will the applicant or future Wilding occupanutme or lurrdk hvsrdous material
As defined by the Cupertino Municipal Code,Clulder 9.12,and the Health and Safety
Code.section 2ss32(a)7
❑Yat WN. All roofs shall be inspected prior to any roofing material being installed.
WIII the applicant or room building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants As defined by the Bay Am!Air Quality Management all new materials for inspection.
District?
❑Ycs (Nu
Ihawneaf the hnardnusmateriaHmyuimmcnu undarC'hepmr6.93afdm Glifw- t
Tia Hcalth@Safety Code,Seedmu25505,75533ud23534.Iundet thmiflhe Wilding
dna net currently haw a mom,that it u my responsibility m malty the oecupanl of the
requirements whit met prior w issuance ora cenifmam of Occupancy.
/O� Signature of Applicant Date
Owner or authorized agent Dam All roof coverings to be Class"B"or better
INVOICE ' INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
• PERMIT INVOICE OPERATOR: suem
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . :
INVOICE DATE. . . . . . : 10/20/2005
REFERENCE ID # . . . : 05100156
SITE ADDRESS . . . . . : 22601 VOSS AVE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : CITY OF CUPERTINO
ADDRESS . . . . . . . . . . : 22601 VOSS AVE
CITY/STATE/ZIP . . . . ,
CONTRACTOR . . . . . . . : GILBERT, GLEN LIC # 21407
COMPANY . . . . . . . . . . : ABLE SEPTIC
ADDRESS . . . . . . . . . . : 520 REED ST.
CITY/STATE/ZIP . . . : SANTA CLARA, CA 95050
TELEPHONE . . . . . . . . : (408)377-9990
FEE DESCRIPTION --ACCT-NUM CHK TOTAL FEE PD TO DATE BAL DUE
____________________ __ --------------
__________ __________
0.00 0.00 0.00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 302 TUB & OR SHOWER '
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING 512 FINAL HANDI-CAP
•
a56 Oo1 >�
CITY OF CUPERTINO
i REPIPE/SEWERS/MAIN SERVICE
CUPERTINO PERMIT APPLICATION FORM
APN # 3 y Z ! S O 3 9� _ 0 Date: /6 2G,, 0.1
Building Address: l
aab o I VoSS
Owner's Name: Phone#:
C(7- �� Cvperi end 777- 3Z72—
Contractor:
77' 3272Contractor:ftPhone: 49 License#:
5, r�
Contact: Phone: Cupertino Business License#:
'l Gc hce�_ 20o7
Building Permit Info:
Bldg ❑ Elect ❑ Plumb/b
Job Description: _
Residential ❑ Commercial
Cost of Project: (� C CO
\J
•
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg. Permit Fees BUILDING
BPGAS Gas Piping System Fee PLUMBING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Repipe of Fixtures. PLUMBING
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING